GW1--03110_Well Construction - GW1_20230428

lL,CONSTRUCTION RECORD(ow-1) For Internal Use Only:
1.Well Contractor information: p�
JeCN "Jr���.s 14.WATER ZONES
Well Contractor Name FROM TO DLSCRUT10N
� 4 Sa ft. 3 5b
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER ap licable
YADKIN WELL COMPANY,INC. FROM I To I DIAMMTER T1310C S MATERIAL.
ft. I ft. I n.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loo )
2.Well Construction Permit#: 02: FROM To pL0rETER I TEaClavEss MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,I-larlance,etc.) 41 R 814 ft G yel in' s og 2k I Pvc J
3.Well Use(check well use): ft. ft. in t
17.SCREEN
Water Supply Well
PP y : FROM TO DIAMETER SLOT S1ZL THICKNESS MATERIAL
❑Agricultural ❑M icipal/Public ft. ft. in. t`9
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACIMIENT METHOD&AMOUNT
Non Water Supply Well: o ft 0 ft' #-6(v e Pa ore a G
❑Monitoring ❑Recovery it. ft Quit k 6roa Pu erg 1®2
Injection Well: ft it.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAPID/GRAVEL PACK ifa licable)
❑Aquifer'Storage and Recovery ❑Salinity Barrier PROM To MATERIAL U1PLACEMI'.NTMrROD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. it.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets ifnecessa
FROM TO DESCRD? ON color,hardness,soil/roek c, in she,etc.
❑Geothermal(Heating/CoolingRetum) ❑Other(explain under#/21 Remarks)
4.Date Well(s)Completed:.3 I;13 WellID#nAj- .579 7$ ft• 3N2 ft ����i
5a.Well Location: Phone #33K•- ��2-32-(U ft ft
Facility/Owner Name Facility IDA(if applicable) ft, ft
ft f`' APR 9
Physical Address,City,and ft ft.'p 1 J6
rr 21.REMARKS ,i r.r?Cgy t
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) 22.Certification:
-9 ®E�._Q NVim, .Q 3 3 W
6.Is(are)the well(s): GFrrrmanent or ❑Temporary Signatar of C ed Well Contractor Date
By signingthisform,7herebycertifythatthewell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well., ❑Yes or 8NOo 15A NCAC 01C.0100 at-15A NCAC 01C.0200 Fell Construction Standards and that a copy
If this is a repair,fell ou/known well construction information and explain the nature of the afthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: % b 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �a (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths If dierent(example-3©200'and 1©100D
8o 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Statiewater level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use ®
11.Borehole diameter: (in.) Bit Off" LO.O 32 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the ti
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
c
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA j
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) I0 Method of test: flfl ®� P
13b.Disinfection type: 70%HTH Amount: 14 OZ DATE SITE VISITED: yd
VISITED BY:
'vartment oflinvuonmenW Ouality-Division of Water Resources Revised 6-6-2018